Percentage of patients shifting to another treatment modality: An experience-guided decision

ABSTRACT Objective: This study aimed to assess the frequency with which orthodontic patients decided to shift to another type of orthodontic appliance, among conventional metal brackets, ceramic brackets, lingual brackets and clear aligner, based on their personal experiences of pain, ulcers, bad breath, hygiene issues and social difficulties. Material and Methods: This study comprises of patients seeking orthodontic treatment. The sample (n = 500; age group = 19-25 years) was divided equally into four groups based on the treatment modality: conventional metal brackets, ceramic brackets, lingual brackets and clear aligner. Patients rated the questionnaire using a visual analogue scale, to assess variables (such as pain, ulcer etc) that impact various treatment modalities. Subsequently, patients from all groups provided feedback regarding their treatment experiences, and expressed their preference for an alternative modality. Intergroup comparison among the four groups was done using one-way analysis of variance with Tukey’s HSD post-hoc test (p ≤ 0.05). Results: Patients who received lingual brackets reported higher levels of pain and ulceration, as compared to those who received clear aligners. All four groups showed statistically significant differences for ulcers during treatment (p ≤ 0.05). Of the 125 patients who received conventional metal brackets, 28% expressed a preference for clear aligner therapy, while 20% preferred ceramic brackets. In the lingual group, 56% of 125 patients preferred clear aligner therapy, and 8% preferred ceramic brackets to complete their treatment. In the ceramic group, 83% did not want to switch, whereas 17% desired to switch to clear aligner, while in aligner group no patient desired to switch. Conclusions: A higher percentage of patients from lingual brackets group chose to shift to clear aligners, followed by conventional metal brackets group and by ceramic brackets group, in this descending order. The clear aligner group demonstrated fewer issues than the other treatment modalities.


INTRODUCTION
Orthodontic advancements, particularly in recent years, have been followed by a large increase in patients' aesthetic and comfort demands.Most studies in this field concentrated solely on the pain experienced by orthodontic patients during treatment.Orthodontic patients are often warned that there may be some discomfort related with the insertion of separators and initial archwires, as well as during periodic orthodontic appliance adjustments.The severity and length of discomfort, on the other hand, are not always discussed.Orthodontic treatment has a variety of negative effects that must be considered while comparing treatment options.In light of the healthcare industry's current emphasis on patient demands, it is important to evaluate patients' experiences throughout treatment.
Although orthodontic therapy has been shown to be effective for achieving occlusal functions and aesthetics demands, many individuals are hesitant to seek treatment, due to the discomfort associated with metal brackets. 1Using conventional metal brackets to align teeth often results in an unusual aesthetic that some people describe as "metallic mouth" or "train tracks." In the late 1970s, patients were given an exciting new option for improving their aesthetics, with the introduction of lingual brackets.Adults who are self-conscious about their appearance typically wear them because they are hidden behind the teeth. 2 Another great characteristic of lingual brackets is that they are Dental Press J Orthod.2024;29(1):e2423133 less likely than traditional metal brackets to cause white spot lesions, but functional difficulties and a prolonged adaptation reduced its use until recent years. 3,4The most significant drawbacks were the increased price of laboratory equipment and the technical restrictions imposed on the staff. 5,6Previous studies examining patient satisfaction with fixed appliances have suggested that some patients may experience pain and discomfort immediately after orthodontic brackets are bonded, as well as sometimes after regular visits.This was negatively correlated with patient satisfaction. 7e introduction of clear aligners has drastically changed the face of cosmetic dentistry.Since their introduction to the market in 1997 by Align Technologies™, clear aligners have quickly become one of the most preferred orthodontic appliances for patients who are concerned with aesthetics. 8Clear aligner system is one of the most sought by patients because of their aesthetics and comfort, compared with other types of treatments.Nevertheless, this system presents limitations in relation to correction of malocclusion, because aligners are deficient in some aspects, such as increase of teeth inclination after use; lack of control of tooth movement, which reflects in their deficiency to rotate roots, considering that in these cases there is need for overcorrection, interproximal accessories or reduction; in addition to having little successful in promoting dental occlusion and performing intrusion and extrusion of teeth.Also, their use is dependent on the cooperation of patients in using them for the recommended period. 9thodontists have long acknowledged that malocclusion and dentofacial anomalies can cause significant physical, social, and psychological distress. 10,11In order to assess orthodontic need and determine the effects of orthodontic care, patient-centred assessments are increasingly being used. 12,13ere is some awareness of what patients hope to achieve with orthodontic treatments, and there is mounting proof that their positive opinions of the procedure have helped them. 14,15ere is, however, limited knowledge of what patients anticipate from the course of orthodontic therapy and from potential side effects beyond discomfort.
Thus, the goal of this study was to determine which group of patients experienced the most discomfort and other related issues, along with the percentage of adult orthodontic patients included in this study.The interval for changing the aligners was 20 days and for changing the orthodontic archwire was 28 days, so that all four groups had one appointment per month.
Based on the 95% power of the study and 5% type I error and effect size of 0.18, the minimum sample size was calculated to be 530 patients (conventional metal orthodontic brackets, ceramic brackets, lingual brackets and clear aligner therapy).
The formula used for this was: The exclusion criteria were: severe crowding (> 8 mm) or extractions, history of orthodontic treatment, use of auxiliaries during or before the study period (e.g., expanders, transpalatal arch, temporary anchorage devices), oral pathology, a significant medical history or medication usage, patients younger than 18 years of age.The responses to the questionnaire having 20% or more of missing data were also excluded.
Five hundred patients who were undergoing orthodontic treatment with conventional metal brackets, ceramic brackets, lingual brackets, or aligners were selected for this study.
The treatment modality was chosen by the patient based on their personal preferences and financial circumstances.
From the total sample, 94.3% responded to the questionnaire, allowing for dividing the final sample evenly between patients who used conventional metal brackets (n=125), ceramic brackets (n=125), lingual brackets (n=125) or clear aligners (n=125).
A total of 0.7% of the patients did not respond to the questions due to their lack of interest in participating in the study.
After providing a detailed information about the survey, an informed consent was taken from the patients.A questionnaire was used to measure patients' expectations of orthodontic treatment after 6-9 weeks (Fig 1).For this, a visual analogue scale (VAS) was used, with a line going from 0 to 10 cm, where 0 cm is no issue and 10 cm is the most serious issue.Please complete the following questionnaire, and mark a point on the line that goes from 0 to 10 cm, where 0 cm is no issue and 10 cm is the most serious issue.The response from each patient was measured on the visual analogue scale with a vernier caliper.To ensure consistency, a subset of data was measured again after a two-week period.
The readings were rounded off to the nearest centimeter.

RESULTS
The intraclass correlation values ranged from 0.788 to 0.988, showing good intraobserver agreement.
A significant difference was seen between all groups, except for the metallic and ceramic brackets (p<0.05)(Table 1).
The aligner patients had the least difficulty in eating (1.97±0.62)and adaptation (1.65±0.55),among all groups.Discomfort after the first-and second-week adjustments was also consistently less for aligner than other groups.For both adaptation and eating difficulty, the conventional metal brackets group showed significant difference with lingual brackets and clear aligner.However, the

GROUPS COMPARISON REGARDING PAIN, ULCER AND EMERGENCY DURING COVID-19
7][18] Fear of pain is one of the main reasons why patients don't seek orthodontic care. 19Miller et al. 20 discovered that patients with conventional buccal brackets experienced

ALIGNER GROUP
NO PATIENT WANTED TO SWITCH more severe pain than patients with lingual brackets.However, in this study, the patients with lingual brackets experienced more pain than other orthodontic therapy, which was consistent with a study done by Shalish et al. 21 et al. 22 reported higher analgesic usage in lingual brackets patients, despite no statistically significant changes in pain levels between buccal and lingual brackets patients, which was similar to the finding of the present study.
Statistically significant differences were observed between the groups with respect to eating disturbances.Previous studies have reported that individuals with lingual impairments exhibited a greater incidence of eating disturbances and an extensive recovery period 7 , which was not consistent with this study, in which the aligner treatment exhibited the least degree of impairment and eating disturbances.Clear aligner patients experienced less impact on their oral health and daily routines than those with lingual, buccal, or ceramic brackets. 20e perception of orthodontic treatment among adult seeking care and the subsequent recommendation of orthodontic therapy for these patients are significantly influenced by psychological adaptation or a sense of well-being.This aspect of orthodontic care and its quantification assumes greater significance in the era of social media, in which opinions and experiences (both positive and negative) are eagerly accessible.Similarly, this study demonstrated that patients using conventional metal brackets were more conscious about their smile and looks in social gatherings.
The patients using clear aligner appliances noticed discoloration, but not from the clear aligner itself, but from attachments.This issue does not exist in the other metal and lingual orthodontic treatment modalities.Patients in the ceramic group frequently complained about staining of their brackets.Although ceramic brackets are more aesthetically pleasing than metal brackets, polycrystalline brackets stain.This is most likely due to the individual's diet, which includes a high intake of caffeine and colas. 25e pandemic has had a continuing effect on the orthodontic treatment, as the orthodontic treatment is a long process that requires regular visits. 26According to Bilder et al 27 , an orthodontic emergency may arise or quickly worsen, necessitating immediate action.Additionally, emergencies may result in oral mucosa or gingiva infection or excruciating pain, according to literature searches performed in PubMed and Embase databases. 27In this study, it was observed that a higher frequency of emergencies was associated with con- aligners have significant advantages. 26When compared with fixed appliances, the clear aligners have better aesthetic and oral hygiene, and are less affected by orthodontic emergencies and skipped visits, since the patient is provided with a set of aligners; hence patients tend to prefer clear aligners over conventional brackets. 28 this study, 48% of patients in the conventional metal brackets group, 62% in the lingual brackets group, and 17% of patients in ceramic brackets group wanted to switch to another treatment modality, while no patient in the aligner group wanted to switch treatment.Hohoff et al 29 found that women under the age of 40 preferred lingual brackets over buccal brackets, while Nedwed and Meithke's 30 showed that women aged 20 to 30 were more likely to choose Invisalign TM over buccal or lingual brackets.In this study, aesthetics (in comparison to buccal brackets), pain, and ulcers (lingual brackets) influenced patients' choices, while a study by Kravitz et al. 31 showed that one in every six patients (17.2%) needed to switch from Invisalign to brackets to finish their treatment.The difference between the two studies may be because this study was based solely on personal experience, and treatment was ongoing, whereas in the study by Kravitz et al. 31 patients had to switch because treatment could not be completed by one modality.
Dental Press J Orthod.2024;29(1):e2423133 6.Among the patients treated with conventional metal brackets, 52% did not want to switch to another orthodontic appliance, 28% wanted to switch to clear aligner therapy, and 20% wanted to switch to ceramic brackets.
7. Within the aligner group, no patient expressed desire to switch to another treatment modality.
There are other factors that may impact the preference of a patient for different types of orthodontic treatments, such as the aesthetic impact of the appliance, as well as other factors that were highlighted in this study.Listening to the patients' opinions, rather than simply reading about their experiences, can provide greater clarity for other patients when making decisions and choosing the best option for themselves.

LIMITATIONS
The findings of the present study are only applicable to patients with minor malocclusion and for the initial length of time investigated in this study.Future randomized clinical trial are needed, with more complex malocclusion and for longer period of time.
who would like to convert to another treatment modality after learning about the disadvantages of various treatment modalities.Conventional metal brackets, ceramic brackets, lingual brackets, and clear aligners were evaluated.Dental Press J Orthod.2024;29(1):e2423133 MATERIAL AND METHODS Approval from the Institutional Ethical Committee of Teerthanker Mahaveer Dental College was obtained for the study (IEC/21-22/OD04).The prospective study was planned to determine patients' experience undergoing treatment with conventional metal orthodontic brackets (Ormco, 3M Unitek), ceramic brackets (3M Unitek), lingual brackets (Incognito, 3 M Unitek, Monrovia) and clear aligner therapy (Aligner, Mumbai, India) after the first six to nine weeks of orthodontic treatment.The patients who came to the Department of Orthodontics and Dentofacial Orthopaedics at the aforementioned institution for their treatment from January 2022 to February 2023, aged between 18-25 years irrespective of their gender, were

Kumari S , 1
Goyal M, Kumar M, Khanna M, Yadav E, Singh T -Percentage of patients shifting to another treatment modality: An experience-guided decision 10 Dental Press J Orthod.2024;29(1):e2423133 Patients were invited to answer a questionnaire about problems like pain, ulcers, bad breath (Fig 1), hygiene issues, hesitation while smiling in social gatherings, difficulties with speech, eating limitations, Covid-19 emergencies, and difficulties in adaptation.Initially, a pilot study was conducted to estimate the time required to complete the questionnaire, which confirmed that the time required to complete the questionnaire was 1 hour.After that, the patients from each group were interviewed together by the same interviewer and given the option to express their views regarding the pros and cons of the different treatment modalities.They were interviewed in the same environment, so that they could listen to the experience of the other patients and have a better understanding of the options available to them, thus making more informed decisions.Following the discussion, patients were asked if they wished to switch to an alternative type of brackets.An audio recording of the interview was conducted, with the purpose of emphasizing the content and verbal prompts, facilitating the interviewer in producing a "verbatim transcript" of the interview.16Kumari S, Goyal M, Kumar M, Khanna M, Yadav E, Singh T -Percentage of patients shifting to another treatment modality: An experience-guided decision Dental Press J Orthod.2024;29(

Figure 1 :
Figure 1: User survey questionnaire for the treatment experience.

Kumari S ,
Goyal M, Kumar M, Khanna M, Yadav E, Singh T -Percentage of patients shifting to another treatment modality: An experience-guided decision 12 Dental Press J Orthod.2024;29(1):e2423133 Descriptive and inferential statistics were analyzed using IBM SPSS v. 20.0 (IBM Corp. Released 2011.IBM SPSS Statistics for Windows, Armonk, NY: IBM Corp).Mean and standard deviation were used to summarize the responses given by the use of VAS.The data normality was checked using the Kolmogorov-Smirnov test, and the distribution was found to be normal.The sample's homogeneity was confirmed by Levene's test and the intraobserver reliability was measured after two weeks, for the evaluation of intraclass correlation coefficient.Intergroup comparison among the four groups was done using one-way analysis of variance with Tukey's HSD post-hoc test.Throughout the study, p-values <0.05 were considered as statistically significant.

Figure 3 :
Figure 3: Groups comparison regarding eating difficulty, adaptation difficulty and hesitation.
Goyal M, Kumar M, Khanna M, Yadav E, Singh T -Percentage of patients shifting to another treatment modality: An experience-guided decision Dental Press J Orthod.2024;29(1):e2423133 Due to shared experiences and similar discomfort, patients in all groups (traditional metal brackets, lingual brackets, ceramic brackets and aligners) were open to switch to other appliance type.Those who opted for ceramic or lingual brackets reported roughly identical levels of satisfaction.Among the patients treated with conventional metal brackets, 28% were open to switch to clear aligner therapy and 20% wanted to switch to ceramic brackets, while the remaining were satisfied with the treatment modality they were undergoing (Fig 5).

Figure 4 :
Figure 4: Groups comparison regarding speech, food impaction and bad breath.

Figure 5 :
Figure 5: Percentage of patients in conventional metal brackets group who wanted to switch their treatment.

Figure 7 :
Figure 7: Percentage of patients in ceramic brackets group who wanted to switch their treatment.

Figure 6 :
Figure 6: Percentage of patients in lingual brackets group who wanted to switch their treatment.

Figure 8 :
Figure 8: Percentage of patients in clear aligner group who wanted to switch their treatment.
ventional metal and lingual brackets as opposed to clear aligners.During the ongoing months of the Covid-19 pandemic, a growing interest in the Invisalign method has been noted.When comparing the treatment duration and chair time, Dental Press J Orthod.2024;29(1):e2423133
The statistical significance in the same row is shown by different superscript letters between different groups (HSD Tukey's post-hoc test).*Statistically significant difference among groups.